Orange County NC Website
Browse       Search
Commissioner Approved Fee Schedule- FY 2017-18 ATTACHMENT 4 36 <br /> Commissioner Approved <br /> Fee Change for Last <br /> De artment/Pro ram Description Current Fee FY 2017-18* Revision <br /> ADA Code <br /> Dental Health D0150 Com rehensive Oral Evaluation $80.00 2013 <br /> Oral Evaluation for a patient under three years of <br /> age and counseling with primary caregiver(26) $61.00 2015 <br /> D0120 Periodic Oral Evaluation $45.00 2013 <br /> D0140 jLmmed Oral Evaluation $69.00 2013 <br /> D0170 Re-evaluation-limited,pblem $65.00 2013 <br /> D9310 Consultation $122.00 2013 <br /> D0330 Panoramic Film $100.00 2013 <br /> D0270 BWX 1 Film $26.00 2013 <br /> D0272 BWX2 Films $41.00 2013 <br /> D0273 Bitewings-thre films $51.00 2013 <br /> D0274 BWX4 Fil- $58.00 2013 <br /> D0220 1 at Intmoral PA Film $26.00 2013 <br /> D0230 Additional PA Film $23.00 2013 <br /> 50240 Intmoral Occulusal Film $38.00 2013 <br /> D0210 Full Mouth Series w BWX $120.00 2013 <br /> D1120 Pro h/Child under a 13 $61.00 2013 <br /> D1110 Pro h/Adult a 13 and i $82.00 2013 <br /> D1203 Fluoride Varnish a 13&under $33.00 2013 <br /> D1204 Fluoride Varnish agc 13-20 $33.00 2013 <br /> Topical Fluoride varnish;therapeutic application for <br /> D1206 moderate to high caries risk Patients $39.00 2013 <br /> D1351 Sealant/NEWLY ERUPTED TEETH $49.00 2013 <br /> R lication of sealant $49.00 2015 <br /> D4342 Scale tots P 1-3 teeth / $167.00 2013 <br /> D4341 Scale Root Planing 4>teeth / $231.00 2013 <br /> Scaling in presence of generalized moderate or <br /> D4346 severe gingival inflammation $0.00(10) $95.00 NEW <br /> D4355 Full mouth Debridement $168.00 2013 <br /> D4910 Periodontal Maintenance $127.00 2013 <br /> D2140 Amal One Surface Prim/Perm $130.00 2013 <br /> 52150 Amal Two Surface Prim/Perm $164.00 2013 <br /> D2160 Amal Three Surface Prim/Perm $198.00 2013 <br /> D2161 Amal Four Surface Prim/Perm $236.00 2013 <br /> D2330 Resin One Surface Anterior $148.00 2013 <br /> D2331 Resin Two Surface Anterior $183.00 2013 <br /> D2332 Resin Three Surface Anterior $227.00 2013 <br /> D2335 Resin Four Surface Anterior $288.00 2013 <br /> D2390 Resin Comp.Crown Ant.Prim $414.00 2013 <br /> D2391 Resin Com.Iam.Post-Prim/Perm $162.00 2013 <br /> D2392 Resin Cam.2sur.Post-Pri.Memi $212.00 2013 <br /> 52393 Resin Cam.3sur.Posterior Perm $261.00 2013 <br /> D2394 Resin Cam.4+sur.POS[edor Perm $314.00 2013 <br /> D9910 Application of De sensitizing Medicament $57.00 2013 <br /> Application of Desensitizing Resin for cervical <br /> D9911 and/or root surface per tooth $70.00 2013 <br /> D3220 P-1ptomy $183.00 2013 <br /> D2930 SSC Primary Tooth $247.00 2013 <br /> D2931 SSC Permanent Tooth $298.00 2013 <br /> D2932 Prebacricated Resin Crown $323.00 2013 <br /> D2934 Prefab.est.coat SSC Prim.Tooth $327.00 2013 <br /> 52940 Sedative Fillip $113.00 2013 <br /> 59110 Palliative Treawets $115.00 2013 <br /> D7140 Ext.Empted Tooth Prim/Pemr $162.00 2013 <br /> 57210 Extraction Surgical-100+ $253.00 2013 <br /> D7111 Ext.comal remnants deciduous $122.00 2013 <br /> D7310 veop lasty extractions /uad. $270.00 2013 <br /> Alveloplasty in conjunction, extraction 1-3 <br /> D7311 teeth per quadrant $273.00 2013 <br /> Alveloplasty not in conjunction with extraction 4 or <br /> D7320 more tooth spaces per quadrats $404.00 1 2013 <br /> * Any fee changes wi I I be included in this column; <br /> a blank beside each fee means there is no fee change in FY 2017-18 Commissioner Approved Fee Schedule <br />